Provider Demographics
NPI:1447294590
Name:GOODWIN, ELIZABETH H (CFNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:H
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 N STATE ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1658
Mailing Address - Country:US
Mailing Address - Phone:601-355-1234
Mailing Address - Fax:601-326-3537
Practice Address - Street 1:1421 N STATE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1658
Practice Address - Country:US
Practice Address - Phone:601-355-1234
Practice Address - Fax:601-326-3537
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR838632363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114550Medicaid
MS500001059Medicare PIN
MSP60159Medicare UPIN